Westen D, Shedler J
Department of Psychiatry, Harvard Medical School, Boston, USA.
Am J Psychiatry. 1999 Feb;156(2):273-85. doi: 10.1176/ajp.156.2.273.
The DSM-IV classification of personality disorders has not proven satisfying to either researchers or clinicians. Incremental changes to categories and criteria using structured interviews may no longer be useful in attempting to refine axis II. An alternative approach that quantifies clinical observation may prove useful in developing a clinically rich, useful, empirically grounded classification of personality pathology.
A total of 496 experienced psychiatrists and psychologists used the Shedler-Westen Assessment Procedure-200 (SWAP-200) to describe current patients diagnosed with axis II personality disorders. The SWAP-200 is an assessment tool that allows clinicians to provide detailed, clinically rich descriptions of patients in a systematic and quantifiable form. A statistical technique, Q-analysis, was used to identify naturally occurring groupings of patients with personality disorders, based on shared psychological features. The resulting groupings represent an empirically derived personality disorder taxonomy.
The analysis found 11 naturally occurring diagnostic categories, some of which resembled current axis II categories and some of which did not. The findings suggest that axis II falls short in its attempt to "carve nature at the joints": In some cases it puts patients who are psychologically dissimilar in the same diagnostic category, and in others it makes diagnostic distinctions where none likely exist. It also fails to recognize a large category of patients best characterized as having a dysphoric personality constellation. The empirically derived classification system appears to be more faithful to the clinical data and to avoid many problems inherent in the current axis II taxonomy.
The approach presented here may be helpful in refining the existing taxonomy of personality disorders and moving toward a system of classification that lies on a firmer clinical and empirical foundation. In addition, it can help to bridge the gap that often exists between research and clinical approaches to personality pathology.
事实证明，《精神疾病诊断与统计手册》第四版（DSM-IV）中人格障碍的分类无论是对研究人员还是临床医生来说都不尽人意。使用结构化访谈对类别和标准进行渐进式改变，可能在试图完善轴II时不再有用。一种量化临床观察的替代方法，可能在开发一种临床丰富、有用且基于实证的人格病理学分类方面被证明是有用的。
共有496名经验丰富的精神科医生和心理学家使用谢德勒-韦斯顿评估程序-200（SWAP-200）来描述目前被诊断患有轴II人格障碍的患者。SWAP-200是一种评估工具，它允许临床医生以系统且可量化的形式提供对患者的详细、临床丰富的描述。一种统计技术，即Q分析，被用于基于共同的心理特征识别患有人格障碍患者的自然分组。由此产生的分组代表了一种基于实证得出的人格障碍分类法。
分析发现了11个自然形成的诊断类别，其中一些类似于当前的轴II类别，而另一些则不同。研究结果表明，轴II在试图“在关节处切割自然”方面存在不足：在某些情况下，它将心理上不同的患者归为同一诊断类别，而在其他情况下，它进行了可能不存在差异的诊断区分。它还未能识别出一大类最适合被描述为具有烦躁人格星座的患者。基于实证得出的分类系统似乎更忠实于临床数据，并避免了当前轴II分类法中固有的许多问题。
这里提出的方法可能有助于完善现有的人格障碍分类法，并朝着一个建立在更坚实的临床和实证基础上的分类系统迈进。此外，它有助于弥合人格病理学研究方法和临床方法之间经常存在的差距。
